Use of antibiotics in pyogenic flexor tenosynovitis.

Pyogenic flexor tenosynovitis is a frequent and serious condition. However, there is no consensus on the use of antibiotics. The objective of our study was to describe the treatment of this condition and to identify the surgical and medical management parameters to propose an effective and consensual postoperative antibiotic therapy protocol. We retrospectively reviewed pyogenic flexor tenosynovitis of the thumb or fingers treated between 01/01/2013 and 01/01/2018 at a teaching hospital. Inclusion criteria were confirmation of the clinical diagnosis intraoperatively and a minimum post-antibiotic follow-up of 6 months. Comorbidities, type of surgery, antibiotic therapy parameters, and treatment outcome were assessed. One hundred and thirteen patients were included. Fifty-four percent had comorbidities. The most frequent germ was staphylococcus, all patients received postoperative antibiotic therapy. Intravenous or intravenous followed by oral administration did not provide any benefit compared to an exclusively oral treatment (p = 0.46). The duration of postoperative antibiotic therapy (less than 7 days, between 7 and 14 days or more than 14 days) did not lead to any difference in healing rate (p = 0.67). However, treating for less than 7 days versus 7-14 days seemed to be associated with a higher risk of failure, although not statistically significant. Oral postoperative antibiotic therapy with amoxicillin + clavulanic acid for 7-14 days appears to be effective, allowing for outpatient management.

Relevance of antibiotic prophylaxis in the management of surgical emergency open hand trauma.

Surgical site infection after emergency hand surgery can cause considerable morbidity and, in the most severe forms, even toxic shock syndrome. Postoperative antibiotic prophylaxis aims to reduce the number of surgical site infections. However, excessive use of antibiotics induces side-effects for patients and antibiotic resistance for society. Contrary to other orthopedic sites, there is no consensus on postoperative antibiotic prophylaxis in open hand trauma beyond analogic reasoning with no proven scientific validity. Our hypothesis was that absence of postoperative antibiotic prophylaxis after open hand trauma surgery does not affect the rate of surgical site infections. A prospective cohort study included 405 patients, operated on in the emergency hand trauma unit without intra- or post-operative antibiotic prophylaxis. Patients were followed up in consultation at 7, 14 and 30 days. Surgical site infection was defined by need for surgery for detersion and flattening, followed by curative antibiotic therapy. The surgical site infection rate was 2.22%. Four patients were lost to follow-up and counted as surgical site infection as originally planned in the worst-case analysis. There were five surgical revisions followed by antibiotic therapy. These results do not differ from those reported in the literature, and thus confirm our hypothesis that postoperative antibiotic prophylaxis is not indicated in open hand trauma management.

Intraneural perineurioma of the median nerve at the elbow: A clinical case.

A 31-year-old female patient presented with swelling on the anteromedial aspect of her right elbow with a sensory deficit in the median nerve territory. Biopsies led to the diagnosis of intraneural perineurioma (INP). Surgical excision was performed and followed by an intercalary graft. INP is a rare benign tumor of the peripheral nerves characterized by a multiplication of perineural cells invading the endoneurium. This lesion is often unknown, under-diagnosed, and its treatment is poorly defined. Few cases have been described in the literature; the majority involve the median nerve at the wrist and no references have been found about its localization to the median nerve at the elbow.

Contrast enhanced ultrasound of carotid plaque in acute ischemic stroke (CUSCAS study).

INTRODUCTION: Carotid atherosclerosis represents 8 to 15% of ischemic strokes in relation to the concept of "vulnerable" plaque. Contrast enhanced ultrasound (CEUS) can detect moving microbubbles within the plaque corresponding to neovessels that constitute "precursors" of vulnerable plaque and intraplaque hemorrhage. CEUS was not studied specifically in acute ischemic strokes. The aim of this study is to analyse the prevalence of CEUS carotid plaque ipsilateral at the ischemic stroke as well as the main characteristics of contrast-plaques. METHOD: A single-centre prospective pilot study involving 33 consecutive patients with a stroke ≤10 days, diagnosed by an MRI with positive diffusion sequence and having a carotid plaque thickness ≥2.5mm with low or heterogeneous echogenicity, located in the ipsilateral carotid territory at the stroke. Plaque echogenicity was done by visual analysis and by measurement of the gray scale median (GSM). A transcranial Doppler monitoring was carried out in search of HITS. The contrast ultrasound was performed after 2.5 cc IV injection of SonoVue®. A video clip was recorded after injection which was used for interpretation by visual analysis in 3 grades, provided by two independent expert readers. RESULTS: The population consisted of 10 women and 23 men aged 73 on average. The topography of strokes in the carotid territory was located on the right in 11 (33%) cases and on the left in 22 (67%) cases. Seventeen patients had carotid stenosis between 0 and 49% according to the Nascet method and 16 patients had stenosis of 50 to 99%. The visual characterisation of the plaques had echolucent dominance (Type 1-2) in 18 cases and echogenic dominance (Type 3-4a) in 15 cases. Cardiovascular risk factors were common with no difference by sex. The inter-observer agreement of plaque enhancement was moderate in first reading (k=0.48) and excellent at consensus (k=0.91). Only one disagreement was found. Contrast agent enhancement of carotid plaque was observed in 11/32 patients, representing a prevalence of 34.4% - CI95% [17.9-50.9]. Variables associated with contrast plaque included the absence of antiplatelet drug (63.6% vs. 23.8%, P=0.05) and the presence of a regular edge on the plaque (91% vs. 48%, P=0.04). There was no difference in contrast enhancement for stenosis>or<50% in diameter and neither for the type of plaque. CONCLUSION: In a consecutive cohort of 33 patients, the prevalence of CEUS from an ipsilateral carotid plaque to a recent acute ischemic stroke was 34.4%. There was a statistically significant association between the contrast enhancement of the plaque and the absence of antiplatelet drug (P=0.05) and also the presence of a regular edge on the plaque (P=0.04). There was no correlation between plaque contrast and clinical and biological characteristics of patients or the presence of HITS.

[Coronary artery spasm revealed by an out-of-hospital cardiac arrest associated with a moyamoya disease. A case report of multimodality imaging]. / Arrêt cardiaque par spasme coronaire associé à une maladie de Moyamoya. Apport de l'imagerie cardiaque multimodale.

Moyamoya disease is a rare angiopathy characterized by a progressive distal occlusion of the internal carotid arteries and their branches. Extracerebral involvement, including coronary arteries, has been described. We report the case of a patient with moyamoya disease who suffered an out-of-hospital cardiac arrest associated with coronary spasm. We discussed the possible links between coronary spasm and moyamoya, as well as the contribution of multimodal cardiac imaging, combining conventional and intracoronary imaging, cardiac MRI, provocative tests for spasm, in the exploration of out-of-hospital cardiac arrest without obvious electrocardiographic and angiographic cause.

Arthroscopic treatment of basal joint arthritis by partial trapeziectomy with ligament reconstruction: Short-term results from a prospective study of 20 patients.

Partial trapeziectomy for basal joint arthritis is an alternative to total trapeziectomy that preserves the height of the thumb column. Using arthroscopy reduces the incidence of periarticular lesions and the risks of complications. The purpose of this prospective single-center study was to evaluate the results of arthroscopic partial trapeziectomy combined with suspension and interposition ligament reconstruction using half of the abductor pollicis longus tendon. Twenty patients (18 women, 2 men) with a mean age of 55 years (43-65 years) were operated using this technique between November 2013 to February 2015. Patients were evaluated clinically and radiologically at 1 month, 3 months, 6 months and 12 months after surgery. The 20 patients were reviewed after 12 months. The subjective QuickDASH score improved from the 3rd post-operative month (P = 0.0029) from 50.6 preoperatively to 30.3 after 3 months, 17.6 after 6 months and 9.6 after 12 months. Pain was reduced in the 1st month post-operative (P < 0.0001). The Kapandji Score and pinch strength improved from the 3rd month (P = 0.034). Return to work was possible for 19% of employed patients after 1 month, 44% after 3 months and 87.5% after 6 and 12 months. Eighty-eight percent of the patients were satisfied or very satisfied after 3 months and 95% after 6 and 12 months. Pain levels, range of motion and QuickDASH Score are similar to those of open partial trapeziectomy described in the literature. However, recovery seems to be faster with this arthroscopic technique. Arthroscopic treatment of basal joint arthritis, which limits capsule and ligament lesions, leads to good short- and medium-term results in terms of pain relief and thumb motion while preserving strength. LEVEL OF EVIDENCE: 4 (Prospective, non-randomized).

Carotid contrast-enhanced ultrasonography and multimodal imaging in a case of TIPIC syndrome.

Transient perivascular inflammation of the carotid artery (TIPIC) syndrome, previously referred to as 'carotidynia', is an unclassified clinicoradiological entity associating atypical acute neck pain, eccentric perivascular infiltration on imaging and improvement of symptoms either spontaneously or with anti-inflammatory treatment. This case report presents a patient with TIPIC syndrome who underwent five different types of imaging modality, including contrast-enhanced ultrasonography (CEUS) of the carotids, and describes the CEUS appearances of TIPIC syndrome.

Carotid diaphragm: Atypical fibromuscular dysplasia or atheromatous lesions?

Atypical fibromuscular dysplasia (FMD) is an underdiagnosed cause of ischemic stroke. The typical angiographic pattern of a septum on the posterolateral side of a carotid megabulb is highly suggestive of atypical FMD. We report here on two patients with this highly suggestive pattern of carotid atypical FMD, but which histological examination revealed to be atheromatous lesions. Interestingly, contrast-enhanced ultrasound of the carotid artery showed enhancement of the spur, which should never be the case with an FMD lesion, which has no vasa vasorum. Our findings suggest that the results of studies reporting stenting of atypical FMD in cervical arteries should be interpreted with caution.

Hamate hook stress fracture in a professional bowler: Case report of an unusual causal sport.

Stress fracture of the hook of the hamate is uncommon and is usually seen in sports involving a club, racquet or bat (i.e., golf, tennis or baseball). It is caused by direct blunt trauma. We report an unusual case of stress fracture with non-union in a 23-year-old professional bowler, probably caused by endogenous constraints, 1 year after the start of symptoms. Treatment consisted of surgical resection of the hook of the hamate. Multimodal imaging of this fracture is reviewed.

[Major upper limb trauma: patients' outcomes in 22 cases]. / Macro-amputation du membre supérieur : que sont devenus les patients ? À propos de 22 cas.

In front of a major upper limb trauma, do we need to make everything possible to keep the limb with the risk of facing poor functional outcomes? This study was performed to evaluate and compare long-term functional, psychological and social outcomes following major upper extremity trauma between patients treated with amputation and those who underwent limb salvage. This was a retrospective monocenter cohort study of 22 patients who sustained an upper limb injury requiring either amputation or limb salvage. The characteristics of the patient, trauma and initial take-care were studied. The outcomes of amputation and upper limb salvage were compared by using functional scores (DASH, Chen), autonomy (activities of the everyday life, work, driving, leisure activities), psychological and quality of life evaluation (NHP, EVA, Russel's score). Twenty-two patients were supported. Eleven limb salvages were performed with six secondary amputations. Sixteen patients were reviewed: five with limb salvage and 11 amputees with a mean follow-up of 12 years and 5 months. All patients were autonomous. There were no significant differences between both groups regarding DASH and NHP scores or to work status and driving ability. Russel's score showed that patients with salvaged upper limb were pleased to have kept it and would recommend this treatment. Although the results of upper limb macro-replantation are sometimes disappointing, the satisfaction for these patients to keep their upper limb and their body integrity seems to justify such upper limb salvage when it is technically possible.

Oral thromboprophylaxis following total hip replacement: the issue of compliance.

INTRODUCTION: Thirty-five to 40 days' thromboprophylaxis is recommended following total hip replacement (THR). Low molecular weight heparin (LMWH) injected by a health professional ensures good compliance. Compliance with recent oral anticoagulants has not been precisely assessed. Oral self-administration, without coagulation monitoring tests, may be a worrying issue in the management of what is a potentially catastrophic adverse event, without prodromal symptoms alerting the patient to the need for regular intake throughout the prescription period. HYPOTHESIS: It was hypothesized that compliance with these new oral anticoagulants is good over the entire treatment period. PATIENTS AND METHOD: The present cohort study prospectively assessed compliance with oral medication (two capsules of dabigatran etexilate [Pradaxa(®)] per day in a single dose at a set time) following THR. An electronic device continuously monitored the day and time of extraction of capsules from the package. All included patients underwent clinical and echo-Doppler examination at day 30±5 after the start of the study. RESULTS: Fifty-six patients were included at their discharge home. Overall compliance was 98.1% (3,188/3246 capsules correctly taken), falling off slightly over time but never below 97.1%. One patient was diagnosed with symptomatic thrombophlebitis 34 days postoperatively, associated with non-compliance at day 11. End of follow-up echo-Doppler found four cases of asymptomatic distal venous thrombosis. There were no hemorrhagic complications. DISCUSSION: The risk of thromboembolic complications diminishes over time, while oral anticoagulants have a wide therapeutic window and relatively long half-life (15-17 hrs). Efficacy was demonstrated, with improved patient comfort and cost-saving. Compliance in the present series was satisfactory. This, however, should not mean that patients not be appropriately informed, as in the present study, so as to improve compliance. LEVEL OF EVIDENCE: Level III, prospective diagnostic.